Pijn en Acupunctuur: acupunctuur werkt pijnstillend bij uiteenlopende pijnsyndromen

Wij zetten diverse vormen van acupunctuur in bij de behandeling van patienten met moeilijk te behandelen pijn, zoals pijn bij kanker, pijn bij posttraumatische dystrofie, pijn bij neurinomen en pijn bij nuerologische stoornissen. Met bepaalde vormen van acupunctuur, zoals bijvoorbeeld de schedelacupunctuur van Yamamoto of regionale electroacupunctuur is de pijnstillende werking van de acupunctuur soms zelfs binnen seconden tot minuten te bewerkstelligen. We zullen hier echter niet onze klinische ervaring bespreken, maar literatuur aandragen voor de discussie of acupunctuur een rol heeft bij pijnbestrijding.

 

Pijn is een belangrijke indicatie voor acupunctuur en er bestaat in ieder geval een grote overeenstemming bij onderzoekers in de literatuur over het feit dat acupunctuur werkzaam is bij:

 

 

Deze indicaties voor acupunctuur staan als een huis en diverse meta-analyses bevestigen steeds weer dat postoperatieve tand en kiespijn en postoperatief braken en misselijkheid significant verminderen na acupunctuur.

 

Hoe duidelijke een pijnsyndroom te omschrijven is, hoe duidelijker het effect van acupunctuur. Zelfs bij pijnsyndromen zoals lage ruipijn en uitsralende pijnen in het been (de zogenaamde pseudoradiculaire syndromen) zijn ook positieve effecten van acupunctuur te vinden. Maar hier spelen zoveel aspecten een rol dat alleen multinationals die bijvoorbeeld nieuwe pijnstillers, zoals de COX-2 remmers ontwikkelen, pas na het uitgeven van een half miljard Euroís de werkzaamheid van die middelen in dit soort syndromen ondubbelzinnig kunnen aantonen. Men heeft namelijk enorm veel patiŽnten nodig om therapeutische effecten te demonstreren. En acupunctuuronderzoek wordt absoluut niet op die wijze gefinancierd. En toch, ondaks dat, is recent aangetoond dat acupunctuur bij osteoartrotische kniepijn evengoed werkt als een klassieke pijnstiller zoals het middel diclofenac (1) en dat acupunctuur versus placecboacupunctuur bij lage rugpijn de pijn significant verbetert (2). Het is belangrijk om op te merken dat een stof als diclofenac veel nare bijwerkingen heeft op o.a. de maag, en dat acupunctuur in handen van professionele therapeuten geen nare bijwerkingen heeft (zie onder kopje veiligheid op onze website).

 

Er is echter veel literatuur die ondersteunt dat acupunctuur analgetisch werkt, dat het mechanisme van acupunctuur via de endogene opiaten tot stand komt en dat de werkzaamheid afleidbaar is uit de effecten die waargenomen kunnen worden op spinale, mesencefale en hypothalame niveaus in het centrale zenuwstelsel. Voor details verwijzen we naar onze website, waar we de experimentele studies bespreken die aantonen dat acupunctuurpunten daadwerkelijk neurobiologische effecten hebben. Er zijn inmiddels zoveel studies op dit gebied, dat zelfs de meest sceptische neurobioloog zal onderschrijven dat er relevante neurofysiologische effecten te meten zijn na acupunctuur die ons laten begrijpen waarom acupunctuur analgetisch werkzaam is.

Verder komen er recent steeds meer studies waaruit blijkt dat bepaalde vormen van acupunctuur zelfs werkzamer zijn dan conventionele vormen van acupunctuur. Zo vond de vakgroep anesthesiologie van de universiteit van Wenen dit jaar dat electrostimulatie van oorpunten bij patiŽnten met nekpijnen significant beter is als pijnbestrijding dan klassieke stimulatie (3)

 

Ook bij patiŽnten die stabiel op pijnstilling zijn ingesteld, en toch desondanks nog pijn hebben, kan acupunctuur een extra en significante pijn stilling bewerkstelligen bij de belangrijke patiŽntengroep met kanker (4)

 

Het mooiste pijnmodel om te toetsen dat acupunctuur werkt bij pijn is postoperatieve tand en kiespijn. Dit is namelijk een duidelijk omschreven pijnsyndroom dat ook goed in diermodellen te onderzoeken is. Daarnaast is uit diverse meta-analyses en overzichten blijkt steeds dat acupunctuur werkt in deze indicatie (5). Veel studies zijn op dit gebied gedaan en vrijwel unaniem wordt de pijnstillende werking van acupunctuur steeds weer bewezen (6). In mooi methodologich onderzoek hebben onderzoekers van het topinstituut in Amerika, de UCLA School of Dentistry, ook aangetoond dat het pijnstillende effect van acupunctuur voor een deel op de endogene opiaten productie berust (7). Dit onderzoek dat bevestigde ander onderzoek waarbij hetzelfde gevonden werd (8). Ook in ons land is door anesthesisten aangetoond dat acupunctuur tijdens een operatie het gebruik van opiaten na de operatie kan verlagen.

Tenslotte is bij postoperatieve tandpijnmodellen aangetoond dat op het niveau van het centrale zenuwstelsel belangrijke genen uitschakelt † en daardoor activiteit van zenuwcellen verminderen die pijn doorgeven.

 

Samenvattend : er kan geen fundamentele scepsis bestaan op gebied van het pijnstillende effect van acupunctuur bij pijn. Want:

 

•  acupunctuur is bewezen werkzaam bij diverse pijnsyndromen,

•  ondanks zeer gering onderzoeksgelden in vergelijking met de farmaceutische industrie is er veel positief onderzoek te vinden op het gebied van acupunctuur en pijnbestrijding,

•  het mooiste pijnsyndroom om aan te meten op methodologische gronden is postoperatieve tand en kiespijn (minste variabiliteit),

•  in deze indicatie is acupunctuur ondubbelzinnig werkzaam; dit blijkt uit vele tientallen onderzoeken,

•  acupunctuur is bewezen werkzaam te zijn via de aanmaak van endogene opiaten,

•  acupunctuur effecten zijn duidelijk waarneembaar in het centrale zenuwstelsel met moderne immaging technieken,

•  nieuwe vormen van acupunctuur die nog weinig onderzocht zijn, lijken zelfs effectiever te zijn dan de traditionele vormen van acupunctuur.

 

Referenties

 

(1) Sangdec C et al. Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. 

BMC Comp and Altern Medicine 2002;3:1-9

 

(2) Molsberger AF, Mau J, Pawelec DB, Winkler J.Does acupuncture improve the orthopedic management of chronic low back pain--a randomized, blinded, controlled trial with 3 months follow up.
Pain. 2002 Oct;99(3):579-87.


This prospective, randomised controlled trial, with three parallel groups, patient and observer blinded for verum and sham acupuncture and a follow up of 3 months raises the question: "Does a combination of acupuncture and conservative orthopedic treatment improve conservative orthopedic treatment in chronic low back pain (LBP). 186 in-patients of a LBP rehabilitation center with a history of LBP >or=6 weeks, VAS >or=50mm, and no pending compensation claims, were selected; for the three random group 4 weeks of treatment was applied. 174 patients met the protocol criteria and reported after treatment, 124 reported after 3 months follow up. Patients were assorted 4 strata: chronic LBP, <or=0.5 years, 0.5-2 years, 2-5 years, >or=5 years. Analysis was by intention to treat. Group 1 (Verum+COT) received 12 treatments of verum acupuncture and conservative orthopedic treatment (COT). Group 2 (Sham+COT) received 12 treatments of non-specific needling and COT. Group 3 (nil+COT) received COT alone. Verum- and Sham acupuncture were blinded against patient and examiner. The primary endpoints were pain reduction >or=50% on VAS 3 months after the end of the treatment protocol. Secondary endpoints were pain reduction >or=50% on VAS and treatment efficacy on a four-point box scale directly after the end of the treatment protocol and treatment efficacy after 3 months. In the whole sample a pain relief of >or=50% on VAS was reported directly after the end of treatment protocol: Verum+COT 65% (95%CI 51-77%), Sham+COT 34% (95%ci 22-49%), nil+COT 43% (95%ci 29-58%) - results are significant for Verum+COT over Sham+COT (P<or=0.02). The results after 3 months are: Verum+COT 77% (95%ci 62-88%), Sham+COT 29% (95%ci 16-46%), nil+Cot 14% (95%ci 4-30%) - effects are significant for Verum+COT over Sham+COT (P<or=0.001) and for Verum+COT over nil+COT (P<0.001). No difference was found in the mobility of the patients nor in the intake of NSAID diclofenac. Our conclusion is that acupuncture can be an important supplement of conservative orthopedic treatment in the management of chronic LBP.

 

(3) Sator-Katzenschlager SM, Szeles JC, Scharbert G, Michalek-Sauberer A, Kober A, Heinze G, Kozek-Langenecker SA. Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: a pilot study.
Anesth Analg. 2003 Nov;97(5):1469-73.

In this prospective, randomized, double-blinded, controlled study, we tested the hypothesis that auricular electroacupuncture relieves pain more effectively than conventional manual auricular acupuncture. We studied 21 chronic cervical pain patients without radicular symptoms with insufficient pain relief (visual analogue scale >5) treated with standardized analgesic therapy. All patients received disposable acupuncture needles on the dominant side on the following acupuncture points: cervical spine, shen men, and cushion. In 10 patients, needles were continuously stimulated (2-mA constant current, 1 Hz monophasic) by using the electrical point stimulation device P-STIM. In 11 control patients, no electrical stimulation was administered. All needles were withdrawn 48 h after insertion. Acupuncture was performed once a week for 6 wk. Patients had to complete a questionnaire assessing pain intensity, psychological well-being, activity, sleep, and demand for rescue medication (lornoxicam and tramadol). The reduction in pain scores was significant in the electrical acupuncture group. Similarly, psychological well-being, activity, and sleep were significantly improved in patients receiving electrical acupuncture, and consumption of rescue medication was significantly less. These results demonstrate that continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM improves the treatment of chronic cervical pain in an outpatient population. IMPLICATIONS: Continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM significantly decreases pain intensity and significantly improves psychological well-being, activity, and sleep in chronic cervical pain patients.

 

(4) Analgesic Effect of Auricular Acupuncture for Cancer Pain: A Randomized, Blinded, Controlled Trial.
J Clin Oncol. 2003 Nov 15;21(22):4120-4126.

PURPOSE: During the last 30 years, auricular acupuncture has been used as complementary treatment of cancer pain when analgesic drugs do not suffice. The purpose of this study is to examine the efficacy of auricular acupuncture in decreasing pain intensity in cancer patients. PATIENTS AND METHODS: Ninety patients were randomly divided in three groups; one group received two courses of auricular acupuncture at points where an electrodermal signal had been detected, and two placebo groups received auricular acupuncture at points with no electrodermal signal (placebo points) and one with auricular seeds fixed at placebo points. Patients had to be in pain, attaining a visual analog score (VAS) of 30 mm or more after having received analgesic treatment adapted to both intensity and type of pain, for at least 1 month of therapy. Treatment efficacy was based on the absolute decrease in pain intensity measured 2 months after randomization using the VAS. RESULTS: The main outcome was pain assessed at 2 months, with the assessment at 1 month carried over to 2 months for the eight patients who interrupted treatment after 1 month. For three patients, no data were available because they withdrew from the study during the first month. Pain intensity decreased by 36% at 2 months from baseline in the group receiving acupuncture; there was little change for patients receiving placebo (2%). The difference between groups was statistically significant (P <.0001). CONCLUSION: The observed reduction in pain intensity measured on the VAS represents a clear benefit from auricular acupuncture for these cancer patients who are in pain, despite stable analgesic treatment.

 

(5) Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systematic review.
Br Dent J. 1998 May 9;184(9):443-7.


OBJECTIVE: Acupuncture is frequently advocated as an effective treatment of dental pain. The question whether or not it is effective for this indication remains controversial. The aim of this systematic review therefore was to assess the effectiveness of acupuncture in dental pain. DATA SOURCES: Four electronic databases were searched: Medline, Embase, CISCOM, and the Cochrane Library. Only controlled trials were included in this review. DATA EXTRACTION: Information was extracted from included studies and entered on standard forms independently by both authors. Methodological quality was assessed using the Jadad score. MAIN RESULTS: 16 such studies were located. The majority of these trials imply that acupuncture is effective in dental analgesia. However, important questions remain unanswered. CONCLUSION: It is concluded that acupuncture can alleviate dental pain and that future investigations should define the optimal acupuncture technique and its relative efficacy compared with conventional methods of analgesia.

 

(6) Lao L, Bergman S, Hamilton GR, Langenberg P, Berman B. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial.
Arch Otolaryngol Head Neck Surg. 1999 May;125(5):567-72

BACKGROUND: Acupuncture is increasingly being used by the general population and investigated by conventional medicine; however, studies of its effects on pain still lack adequate control procedures. OBJECTIVES: To evaluate the (1) efficacy of Chinese acupuncture in treating postoperative oral surgery pain, (2) validity of a placebo-controlled procedure, and (3) effects of psychological factors on outcomes. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING:
Dental School Outpatient Clinic, University of Maryland at Baltimore . PARTICIPANTS: Thirty-nine healthy subjects, aged 18 to 40 years, assigned to treatment (n=19) and control (n=20) groups. MAIN OUTCOME MEASURES: Patients' self-reports of time until moderate pain, time until medication use, total pain relief, pain half gone, and total pain medication consumption. RESULTS: Mean pain-free postoperative time was significantly longer in the acupuncture group (172.9 minutes) than in the placebo group (93.8 minutes) (P=.01), as was time until moderate pain (P=.008). Mean number of minutes before requesting pain rescue medication was significantly longer in the treatment group (242.1 minutes) than in the placebo group (166.2 minutes) (P=.01), as was time until medication use (P=.01). Average pain medication consumption was significantly less in the treatment group (1.1 tablets) than in the placebo group (1.65 tablets) (P=.05). There were no significant between-groups differences on total-pain-relief scores or pain-half-gone scores (P>.05). Nearly half or more of all patients were uncertain of or incorrect about their group assignment. Outcomes were not associated with psychological factors in multivariate models. CONCLUSIONS: Acupuncture is superior to the placebo in preventing postoperative dental pain; noninsertion placebo procedure is valid as a control.

 

(7) Simmons MS, Oleson TD. Auricular electrical stimulation and dental pain threshold.
Anesth Prog. 1993;40(1):14-9.

A modified double-blind evaluation of naloxone reversibility of dental analgesia produced by auricular electrical stimulation (AES) was examined in 40 subjects assigned randomly to one of four groups: AES followed by saline (AS), AES followed by naloxone (AN), placebo AES followed by saline (PS), and placebo AES followed by naloxone (PN). Dental pain threshold was tested using a hand-held dental pulp tester. A second investigator administered the true or placebo AES using an electrical stimulator. A third investigator injected intravenously saline or naloxone. The subjects and investigators 1 and 3 were blind to all treatment conditions. A repeated measures analysis of variance revealed a significant difference among the four groups. The AES groups exhibited a statistically significant 18% elevation of pain threshold, whereas the two placebo stimulation groups (PS and PN) remained essentially unchanged. The mean pain threshold increased to more than 23% for group AS, but fell to less than 12% for the subjects in group AN, who were given naloxone. These findings indicate a small but significant elevation of pain threshold by AES, an effect partially blocked by naloxone, suggesting an endogenous opioid system as one mechanism for AES analgesia.

 

(8) Ernst M, Lee MH. Influence of naloxone on electro-acupuncture analgesia using an experimental dental pain test. Review of possible mechanisms of action.
Acupunct Electrother Res. 1987;12(1):5-22.


The purpose of this study was to examine in man the analgesic effect of non-segmental electroacupuncture (EA) limited to a single point (Hoku hand point) and the influence of naloxone using an original modified electrical dental pain test. Results in the literature are still contradictory as to the degree and specificity of acupuncture analgesia and its opioid nature. Acupuncture techniques as well as experimental pain models are factors accounting for the discrepancies in the results. For this reason, we designed an experimental pain test characterized by a high degree of specificity, validity and reliability. We chose optimal conditions for eliciting specific acupuncture effect, i.e. non-segmental, low frequency and painful intensity range. A cross-over repeated measure experimental design was used. Five normal trained subjects participated in 65 sessions under four conditions (control, EA, EA+naloxone, EA+placebo). Changes in experimental dental pain thresholds served as indices of analgesia. The results indicated a 27% pain threshold increase after 30 minutes of EA stimulation (p less than .0001), with no differential effect between pain detection (mild pain sensation) and pain discomfort (strong pain sensation). This increase was partially blocked by the double blind injection of 0.8 mg naloxone IM (p less than .005). The experiment was designed in such a way as to prevent the occurrence of a stress analgesic effect. The endogenous opioid system was shown to be partially involved in acupuncture analgesia. Other mechanisms of action are discussed in view of the literature findings.

 

(9) Sheng LL, Nishiyama K, Honda T, Sugiura M, Yaginuma H, Sugiura Y. Suppressive effects of Neiting acupuncture on toothache: an experimental analysis on Fos expression evoked by tooth pulp stimulation in the trigeminal subnucleus pars caudalis and the periaqueductal gray of rats.
Neurosci Res. 2000 Dec;38(4):331-9.


To clarify the antinociceptive mechanism of acupuncture on acute pain, c-fos protein (Fos) expression induced by tooth pulp stimulation was immunohistochemically examined in the spinal trigeminal subnucleus pars caudalis (spVc) and the periaqueductal gray (PAG) of rats with or without Neiting acupuncture. The central projection of trigeminal ganglion neurons innervating in the tooth pulp was examined by tract-tracing method with horseradish peroxidase-conjugated wheat germ agglutinin (WGA-HRP). Central terminals from the first maxillary molar tooth were labeled transganglionically in the dorsomedial part of spVc with WGA-HRP. Numerous numbers of Fos-immunoreactive (Fos-ir) cells were found in the spVc and PAG by stimulation of the tooth pulp with acetic acid or saline. Neiting acupuncture significantly reduced the Fos expression in the spVc induced by tooth pulp stimulation. On the other hand, Neiting acupuncture evoked many Fos-ir cells in the PAG. The present results suggest that Neiting acupuncture activated PAG neurons that sent descending inhibitory fibers to medullo-spinal nociceptive neurons, and reduced the number of Fos-expressed neurons in the trigeminal subnucleus pars caudalis mediating noxious information from teeth to the higher central nervous system.